Screening for Functional Cognition Using a Simple Performance-Based Test of Cognition and Medication Management

PURPOSE: Occupational therapists assess functional cognition in order to estimate an individual’s ability to manage everyday challenges in instrumental activities of daily living (IADLs) (Wesson, 2016). Performance-based screening tools are used to identify whether or not an individual is at high risk for impaired functional cognition significant enough to impair essential IADLs and community independence (Sedgwick, 2014) and medication management tasks are believed to be an effective early indicator of such impairments (Smith, 2017). The purpose of this study was to examine the utility of a performance-based practical revision of the Medication Transfer Screen, the Mini-Cog, and the Mini-Cog combined with the Medication Transfer Screen (Medi-Cog), as functional cognition screening measures.

DESIGN: A cross-sectional observational design was used to assess a convenience sample of 185 community residing adults. This population was selected as individuals living in the community are the most likely to be discharged back to community living following an acute or post-acute hospitalization (Gaugler et al, 2007). Inclusion criteria for participants included: age 55 years and older, living independently in the community, and able to read and communicate in English.

METHOD: Study participants were administered the Brief Interview of Mental Status (BIMS), Trail-Making Tests (TMT) A and B, Montreal Cognitive Assessment (MoCa), the Mini-Cog, the revised Medication Transfer Screen, the PASS Medication Management, Shopping, and Checkbook Balancing tasks, and the Alzheimer’s Disease Cooperative Study –Activities of Daily Living Inventory Scale (ADCS), a measure of basic and IADL. Individual ROC curves were computed for each of the measures using the PASS shopping and checkbook balancing tasks (PSCT) as index measures. Sensitivity and specificity of the Mini-Cog, revised MTS, and the Medi-Cog were calculated compared to the PSCT. The PSCT was used as a criterion measure as these two tasks, shopping and checkbook balancing, have demonstrated discriminative ability to distinguish between older adults with mild cognitive impairment from cognitively normal older adults (Rodakowski et al., 2014).

RESULTS: The Medi-Cog was best able to identify those individuals identified as impaired on the PSCT. The Medi-Cog demonstrated an AUC (area under the curve statistic) of 0.82, higher than the Mini-Cog (.75) or the revised MTS (.73). Sensitivity of .78 and a specificity of .71 was obtained for classification as impaired on the PSCT task, using a cut score of 8 on the Medi-Cog. The revised MTS identified 42.86% of the individuals as impaired who were identified as impaired on the PSCT while the Mini-Cog identified 51.95%. The combination of these two tasks, the Medi-Cog, identified the highest percentage of true positives (61.04%). Additionally, the Medi-Cog had fewer false negatives (39%) in comparison to the Mini-Cog (48%.) and revised MTS (57%).

CONCLUSION: The Medi-Cog demonstrated greater sensitivity and specificity than other brief screens in identifying impairment on the PSCT. The Medi-Cog may be effective in identifying persons at risk for post-discharge IADL impairment.

IMPACT STATEMENT: The Medi-Cog is a simple to score, screening measure with potential to identify individuals with impaired functional cognition who are at risk of IADL impairment.

References

Rodakowski, J., Skidmore, E. R., Reynolds, C. F., Dew, M. A., Butters, M. A., Holm, M. B., … Rogers, J. C. (2014). Can performance on daily activities discriminate between older adults with normal cognitive function and those with mild cognitive impairment? Journal of the American Geriatrics Society, 62(7), 1347-1352. doi:10.1111/jgs.12878

Sedgwick, P. (2014). Measuring the performance of screening tests. BMJ, 348, 1-3. doi:10.1136/bmj.g4438

Smith, D., Lovell, J., Weller, C., Kennedy, B., Winbolt, M., Young, C., & Ibrahim, J. (2017). A systematic review of medication non-adherence in persons with dementia or cognitive impairment. PLOS ONE, 12(2), 1-19. doi:10.1371/journal.pone.0170651

Wesson, J., Clemson, L., Brodaty, H., & Reppermund, S. (2016). Estimating functional cognition in older adults using observation assessments of task performance in complex everyday activities: A systematic review and evaluation of measurement properties. Neuroscience and Behavioral Reviews,68, 335-360.